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As a new generation enters surgery and as the number of women in the field is (slowly) increasing, one could hope that this also changes surgical culture. But does it? Judith Belle Brown and colleagues asked themselves exactly this question and conducted an interview study with academic surgeons.

Despite the fact that women still reported more struggles to achieve a good work-life-balance, participants overall noted that surgical culture was indeed changing and that surgeons were no longer expected to devote every waking hour to their jobs. For example, one participant noted: “I think things have changed over the years…I mean surgery in the past has been you just work hard, this is your life, and I think it’s changing a little bit … you are allowed to have a life outside. I think that’s good.”

Moreover, participants stated that this change did not only affect attitudes towards work-life-balance in general, but also attitudes towards childcaring responsibilities. One surgeon said: “I think the younger male colleagues, like my generation, it’s a bit different. We’re seeing more and more male surgeons who are doing more stuff at home … and they’re also having to leave early to pick up their kids because their wife is working too… So it’s changing. It’s not like how it used to be, 20 or 30 years ago.”

There is a lot of research on how women in male-dominated areas (e.g. management or politics) are in a somewhat “damned if you do, damned if you don’t” situation. When they present themselves in a warm and feminine way their demeanor is at odds with what the field requires (e.g. they’re not perceived as “real leaders”), but if they present themselves in a masculine, assertive way, they’re not perceived as “real women” and thus disliked. So is that also the case in surgery? A recent study by Marie Dusch and colleagues suggests that this may not necessarily be the case, at least not from the patients’ perspective.

They presented patients in a general hospital with short scenarios describing either a male or a female surgeon who presented themselves in either a feminine or masculine way. Moreover, they were described as either performing breast cancer surgery or lung cancer surgery. Somewhat surprisingly (at least to me) patients did in general not prefer male surgeons over female surgeons or masculine surgeons over feminine ones. Neither did they prefer masculine male surgeons to feminine male surgeons or feminine female surgeons to masculine female surgeons – nor the opposite. In fact, the only significant result they found was that for lung cancer surgery, masculine surgeons were seen as more competent regardless of gender.

While it is important to replicate these results before drawing strong conclusions, this study nevertheless shows that gender stereotypes in surgery may be slowly changing or at least not be as pervasive among patients as we might assume.

We’ve highlighted the importance of role models in general and female role models in particular in a number of quite a few of our past posts. Research suggests that role models serve different functions and lead to different outcomes and that gender is not necessarily important for all of them. However, other studies suggest that gender does matter, especialy in domains in women are under-represented, and one reason why that might be the case is that they can change stereotypes.

STEM/M fields in general and surgery in particular are stereotypically associated with men and maleness. The first person one might imagine when thinking about a surgeon is likely to be a man and when asked to describe a surgeon, stereotypically masculine traits such as “cold” might be used. The so called Stereotype Inoculation Model developed by Nilanjala Dasgupta argues that role models might act as a “social vaccine” and inoculate against these stereotypes which prevent women from entering or staying in STEM/M fields.

She proposes that when exposed to other minority members in one’s domain (e.g. other women in surgery), minority members can identify with this person, which then leads to changes in stereotypes and a stronger identification with the field (e.g. with surgery), but also a more positive attitude towards the field, social belonging in the field, perceived threat and one’s perceptions of one’s own abilities.

Thus, while male role models might be just as effective in some regards (e.g. for learning by emulation), visible female role models in surgery are important – not just for those women already on their path to becoming surgeons, but also for those who might not have made their career choices yet.

Quite shockingly – and we sincerely hope that this fact has changed in the 15 years since this study was conducted – almost half of the over 4000 participants report a history of sex-based harassment in a medical setting. Younger physicians were especially likely to report a history of sex-based harassment. Moreover, this was predictive of all three measures of career satisfaction: whether they felt satisfied, whether they would choose to become a physician again and whether they would like to change their specialty.

This shows that sex-based harassment is indeed a problem in the medical profession and the fact that especially younger women reported experiences of sex-based harassment in the workplace suggests that there is not necessarily a decline in sex-based harassment in medicine. The topic therefore needs to be addressed.

The lack of female role models is often cited as one reason of the under-representation of women in various fields – surgery among them – and psychological research shows that role models can indeed be very beneficial. They can teach us how to reach our goals, demonstrate that goals are attainable and inspire us to adopt new goals. However, some women in surgery argue that role models don’t necessarily need to be female and that male role models can be just as effective.

A study by Lori Bakken suggests that it depends. Women and men in different career stages were asked about their own ability beliefs with regards to a number of skills such as scientific writing. They were further asked about who they envisioned as an expert role model while making those assessments as well as a number of questions about this role model. For example, they were asked which important qualities the expert had. Results showed that male and female participants who described a male role model did not differ in what skills they based their role model selection on. “Multiple publications”, “supportiveness” and “scientific knowledge” were most widely reported both by male and female participants. Female participants who had chosen a female expert, however, reported “problem solving abilities” and “communication skills” more frequently in comparison to men who had chosen men.

Thus, it seems that men make just as good role models for women who are looking for similar qualities in a role model as their male counterparts do. However, for those who value other qualities such as problem solving ability or communication skills, female role models might be more important.

In order to address the under-representation of women in surgery it is important to understand what female medical students deem important in their future careers. Do they value the same things as their male counterparts and just don’t think that they can achieve those goals in a surgical career or are they actually looking for different things in their careers? A study by Nancy Baxter and colleagues suggests that the latter is the case.

They sent out a questionnaire to Canadian medical students and found that men and women named different factors as important for choosing their specialty. Women placed more importance on the availability of part-time work and parental leave as well as residency conditions, while men valued technical challenge, prestige and earning potential. As both male and female students agreed that surgeons earn a lot of money but do not have high quality family lives, it is not surprising that of the participants, men were more likely to choose surgery as the specialty they were pursuing or considering to pursue.

This study once again highlights two facts: First, it is important to make surgery a career in which family related goals can be achieved by both men and women, and second, the fact that a family and a career in surgery can be combined needs to be communicated effectively to medical students.

Work-life-balance or the anticipated and actual lack thereof is a widely cited cause for the under-representation of women in surgery. This is especially true for women who have a family or are planning to have one as women continue to carry most of the weight when it comes to childcare and household chores.

A study by Sullivan and colleagues investigates this issue in a large sample of surgical residents in the US. They found that generally married residents and those with children have the highest levels of work satisfaction. However, this difference was driven by male participants. As expected, female residents reported high levels of stress regarding home life as well as finances when they were married or had children.

These results once again stress that while creating equal opportunities at work is important, it is not enough to tackle gender inequality. As long as women continue to be responsible for more family related work, it is thus crucial to go beyond that and provide them with opportunities to combine both work and family and still achieve a good work-life-balance.

Research generally suggests that women receive more social support than men in terms of emotional support. However, there is also evidence that when working in male-dominated fields, women often receive less support in terms of being provided with important information or instrumental help with work tasks. A questionnaire study by Jean Wallace from the University of Calgary investigates these issues in the medical profession.

In line with previous research she finds that women receive (or at least report receiving) more emotional support than their male colleagues. However, her results do not show a gender difference in instrumental support and women actually report receiving more rather than less informational support.

This is encouraging in that it shows that women are actually well integrated in supported in the medical field. On the other hand, the results might also simply be a reflection of the fact that women are more willing to admit receiving help.

This week, we have once again a guest post. This time, it’s by the awesome KBW, whose blog I can highly recommend. Also, we love guest posts, so if you are interested in writing one, please get in touch!

Much as changed in the near 20 years I have been in and around the medical profession and the progressive feminisation has been wonderful to see and be part of.

There are many women in surgery, far more now than when I was a medical student and I don’t think there is any real problem with being a woman in surgery. Some of the women in surgery I encountered early in my career had children and husbands but very few of them were living a life I aspired to. In fact, if anything they put me off and some made me feel even less welcome than the boys. I don’t know if you’ve ever seen the movie Legally Blonde, imagine that but everyone in white coats; times have changed though and we have a gradual spread of women throughout surgery, not all of whom are doing it like the men did.

I have to acknowledge my parents input, who have an unshakeable belief (which they passed on to me) that I can do anything that I want to do. I was never expected to be slower, weaker or less at anything compared to my brothers and male cousins so not doing general surgery because I was a girl never crossed my mind.

It was on everyone else’s mind though, when I first started popping up in theatre as a super keen student and junior house officer the animosity from some middle grade doctors and the theatre nurses was incredible, I was never expected to actually, really be a surgeon. Also, some well meaning consultants would gently suggest that maybe I would change my mind about general surgery once I had a husband and children and would I really want to work weekends and night shifts forever? Maybe I would think about doing general practice?

We now have hordes of female medical students and junior doctors all wanting to do surgery, most of whom want to come and spend some time hanging about with me. I am aware that as the part time mummy surgeon in great shoes I have a responsibility as a role model to them. When I was a medical student I would have run a mile from the likes of me, but this lot are sent to me by my colleagues to get “the talk”. Three things about this situation bother me, which I no doubt contribute to by seeming approachable.

Firstly, they seem to think that my personal life and circumstances are something that they can ask all about. How do I organise my childcare? Have I encountered any discrimination problems? How do I manage to get up and dressed and organise things and get there for 0745? How much maternity leave did I take? Do I ever feel guilty about leaving my children and not making it home for bedtime? So far nobody has asked me if I had vaginal deliveries but they have gotten close.

I don’t mind this when it is a doctor I actually know, someone who is considering embarking on a career as a surgeon but I do mind having to tell every student that comes through the department about how my kids are looked after and whether or not I have a cleaning lady (I do, twice a week in fact, so I can get to the gym on my days off and not spend the time ironing) or if I do the cooking at home. They also want to know what Mr KBW does and how we make our marriage work with our busy schedules. This seems totally irrelevant to being a surgeon and more to do with being a mummy and a wife, it amazes me that these young girls are thinking about their 35 year old selves, I certainly never did.

The other thing that bothers me is that some are entirely focused on being discriminated against because they are a woman. This has not been my experience at all, there have been very few people (one particularly rude man who is responsible for most of the bile duct injuries within 100 miles of Bighospital) who have openly discriminated against me.

The only real problem I’ve had because I am a woman is getting elbowed in the chest during laparoscopic surgery all the time and trying to accommodate my enormous 38 weeks pregnant abdomen at the table during laparotomies. Not that I think being female has made it easier, even if my colleagues (and so called friends) said my viva exams were dumbed down because I was the pretty girl. Maybe they were, but I knew the answers to the harder stuff as well so bollocks to them.

Finally, not one single boy has ever especially come to me or been sent to me to discuss a career as a surgeon, perhaps they get sent to the men.

So what do I tell these girls in “The Talk”?

I admit there is the endless everyday sexism that all women encounter but I suspect it is not any different for women in law, the police, schools and offices. They see this on the ward round, in clinic, with my bosses and there is no point ignoring it. For example, I won a prize last month and was quite pleased about it “well done” said my boss “a lot of guys on the panel?” as he gave me a “friendly” tug on my pony tail, ho ho. This is everyday sexism, as are the patients who reply “all the better for seeing you sweetheart” when I do my rounds and enquire how they are; it used to flummox me or make me angry or embarrass me.

This isn’t discrimination based on gender, but it is sexist behaviour. It could be demeaning if I let it demean me. So I tell the students that they will experience very little discrimination but occasional sexism but it probably isn’t any worse than in any other job.

I tell them that they have to love surgery because it will take them away from people they love. They have to love it like a crazy obsessed stalker lady. First days at school, Christmas Day, nativity plays, family birthdays, your wedding anniversary…the list of days you won’t and can’t be there is endless. If you don’t love your job you will resent the time you spend there when you feel you should be somewhere else and that makes you a bad doctor. The hours at the computer writing papers, the long trips travelling cheaply to conferences alone, the late nights etc.

Surgery is like a boyfriend who constantly makes you prove how much you love him and plays games with your feelings. The semi mandatory research PhD and MD degrees are like getting a tattoo of his name and just when you think he loves you, and you and he are getting on so well he will punch you in the face with a complication that makes you buckle at the knees.

I also tell them to speak to people about it and urge them to get feedback on their hands and technical skills. Not everyone can do surgery and the sooner you realise that you have hands suited for a career as an occupational health physician the better. I also try and discourage them from being rigidly attached to a specialty very early. Better to want to be a surgeon and consider all the surgical specialties early on than having your heart set on being a head and neck cancer surgeon from the age of 19.

Again, to use the boyfriend analogy, not many people who are determined to find and marry a blonde 6 foot welsh rugby player, 2 years older than them, with no baggage, minimal chest hair, nice feet and works as a vet in the country end up doing so (trust me on this one, I know the woman who wanted this and she is 38, lonely and miserable). So keep your options open and consider all types of surgery.

It also helps to have role models and mentors to guide and influence you. They don’t need to be told that they are your role model, there is no need to formalise the process. Mine have been almost entirely male, there have been about four that have massively influenced my professional and personal life for either a brief period (an amazing plastic surgeon who wrote plays and was an amateur actor) or the few that have been around for most of my adult life (the great leaders).

What most of mine have in common is a rich and varied life out with medicine; all are excellent surgeons and lead their teams well, they are well liked and respected and are exceptionally nice and clever people. These characteristics are not gender specific, as a group they probably are slightly more effusive than other male surgeons but they are all white, British, quintessential Royal College material men. There are of course a few women that have influenced me, one in particular that is about 5 years ahead of me has taught me a lot more than just how to operate and it has been interesting to watch her go from stage to stage and see the few mistakes she has made and the many things she has done right and continues to refine.

Find people you want to be like and ask them how they got there. That might be the workaholic, hugely productive university professor who spends every second at work and publishes endlessly. It might be the guy in the super flash suit whose patients love him and he works tirelessly for them. It might be the forgetful, kind hearted amazing surgeon who can teach almost anyone to do anything.

Above all else, realise that this is a journey where there is no final destination. You will always be learning, always trying to get better, always be teaching others and trying to get better at teaching others.

There is nothing I would rather do than my job, it is the greatest privilege and the most amazing challenge and it is super fun and makes me happy. Not many people can say that about their work, so find a role model that smiles on the way into the hospital and looks happy in theatre because that’s how you should want to feel too.

Affirmative action policies often encounter resistance even among those groups who they are designed to help. One of the reasons for this is that they are typically implemented in a “top down” fashion: Those in leadership positions within or outside of an organisation identify the need for affirmative action, decide on the policies and “force” them on the organisation.

A study by Louise McCall and colleagues addresses this issue by investigating whether a “bottom up” approach is more effective. They used focus groups to raise awareness of the under-representation of women in senior positions in academic medicine and to develop equal opportunity strategies. This approach did indeed result in a number of benefits. Not only did members of the focus groups come up with their own ideas of addressing gender inequality, but members of the faculty were also more accepting and supportive of the developed affirmative action strategies.

Lack of acceptance of affirmative action has been shown to be one of the main barriers to its effectiveness. Using focus groups or other “bottom up” approaches might be a great way of circumventing this problem and tackling inequality issues more effectively.